Kembara Xta - Medicine - Acute Diarrhea

Kembara Xta - Medicine - Acute Diarrhea 
Introduction 
 An abnormal rise in stool water content, volume, or frequency (three times per day) lasting for at least 14 days.
Most frequently a result of an infectious cause; frequently self-limited
The most frequent cause of infectious diarrhea is acute viral diarrhea (50–70%), which is non-inflammatory and watery.
- Frequently includes accompanying nausea and/or vomiting - Usually self-limited; symptoms appear after an incubation period of less than a day.

 Preformed enterotoxin-induced diarrhea manifests within 1 to 6 hours of consuming contaminated food, but diarrhea caused by bacterial infection normally manifests between 1 to 3 days. Bacterial diarrhea (15–20%) is the most prevalent infectious cause of inflammatory (bloody) diarrhea.
– Antibiotic use shortens the duration and/or severity of the sickness; symptoms often go away in 1 to 7 days.
- Be suspicious if other people who have shared potentially contaminated food are also ill.
Protozoal infections (10–15%) – Usually result in noninflammatory (watery) diarrhea – Long incubation period and lengthy disease course, symptoms appear about 7 days after exposure and frequently last more than 7 days.
Traveler's diarrhea (TD), which typically starts 3 to 7 days after arrival in a foreign country and resolves within 5 days, is suspect when outbreaks of watery diarrhea occur in areas with contaminated water or food supplies.

Acute diarrhea causes more than 128,000 hospital admissions in the United States and 2.5 million annual fatalities worldwide. Acute diarrhea is more common in children in underdeveloped nations than in affluent ones.

Acute diarrhea affects 11% of the general population and is the second greatest cause of mortality in children under the age of five and the seventh leading cause of death overall. In underdeveloped countries, contaminated food and water are the main causes of acute diarrhea.

Pathophysiology and Etiology 
Bacterial: Yersinia enterocolitica, Salmonella, Shigella, Campylobacter jejuni, Vibrio parahaemolyticus, and Vibrio cholerae
Listeria monocytogenes, Clostridium difficile, Staphylococcus aureus, Bacillus cereus, Clostridium perfringens, and Clostridium difficile
Rotavirus and Norovirus (most prevalent)
Astrovirus, Cytomegalovirus, and Adenovirus (in immunocompromised)
Giardia lamblia, a protozoal
Enamoeba histolytica
- Cyclospora, Microspora, Cryptosporidium, Isospora belli

Pathophysiology: Viral infections are most frequently non-inflammatory. Increased intestinal discharges without a break in the mucosa; a watery personality
Viral diarrhea causes changes in small intestine cell morphology, including villous shortening, an increase in crypt cells, and an increase in the cellularity of the lamina propria. Inflammatory diarrhea is typically caused by invasive or toxin-producing bacteria that disrupts mucosal integrity and causes tissue invasion and damage.
Bacterial diarrhea causes mucosal hyperemia, edema, and leukocytic infiltration as a result of bacterial invasion of the intestinal wall.

Risk factors include: traveling to developing nations; failing to follow food and water safety precautions; immune-compromised hosts (HIV, cancer, chemotherapy); recently being hospitalized; using antibiotics; using proton pump inhibitors (PPIs); being exposed to children in daycare; having fecal-oral sexual contact; living in a nursing home; and being pregnant (12-fold increased risk for listeriosis).

Prevention 

 The frequency of diarrhea is reduced by about 30% when hands are washed often.
Adhere to the "boil it, peel it, cook it, or forget it" rule when handling food and water, especially when visiting foreign countries. Steer clear of undercooked meat, raw seafood, and unpasteurized milk.
Typhoid and cholera vaccines (for travel to endemic areas) Rotavirus vaccination (for newborns)
Prevention of TD:
- Advice on high-risk foods and beverages given to travelers
– Consider daily prophylaxis with bismuth subsalicylate (BSS) in all travelers; typical dosage is 2 tablets (262 mg each) or 2 oz (60 mL) of liquid formulation 4 times day. - Avoid routine antibiotic prophylaxis. The Infectious Disease Society of America advises chemoprophylaxis with fluoroquinolones when needed, namely norfloxacin 400 mg/day or ciprofloxacin 500 mg once or twice each day. The prophylactic value of probiotics, prebiotics, and synbiotics is unknown.


Associated Conditions: Immunocompromised (HIV, cancer, chemotherapy); Inflammatory Bowel Disease (IBD);

Description of stools—characteristics and output - Frequency; quantity; consistency; character: presence of mucus, blood, or fat; floating - Giardia associated with pale, greasy stools. Historical clues for dehydration include orthostatic hypotension, dizziness, increased thirst, decreased urine output, or altered mental status.

Weight loss; Symptoms such as altered appetite, bloating or pain in the abdomen, nausea, or fever; Risk factors for acute diarrhea; Cirrhosis (linked to Vibrio); Hemochromatosis (linked to Yersinia);


clinical assessment 
Determine the degree of dehydration by looking for symptoms such as ill-appearing, dry mucous membranes, tachycardia, orthostatic hypotension, decreased skin turgor, delayed capillary refill, and impaired mental status. These symptoms may not be present in early dehydration.
Fever is more indicative of diarrheal inflammation.
Check for nodules or enlargement in the thyroid.
Assess the abdomen for distention, stiffness, and discomfort on rebound.
Rectum: bleeding, discomfort, and stool quality
Aspects of Geriatrics
Overflow diarrhea coupled with persistent constipation might be brought on by fecal impaction or an obstructing tumor.

Differential Diagnosis: Diverticulitis, Ischemic Colitis, Spastic (Irritable) Colon, Malabsorption, Medications (Cholinergic Agents, Magnesium-Containing Antacids, Chemotherapy, Antibiotics),
Fecal impaction, thyroid illness, neoplasia, and endocrinopathies


Initial test results from the laboratory and imaging
Reserve laboratory testing for patients with a persistent fever, moderate-severe illness characterized by the passing of less than 6 stools per day, duration of more than 72 hours, dysentery, excessive watery diarrhea, immunosuppression, or if an epidemic is suspected.

Leukocytosis, anemia (blood loss), eosinophilia (parasite infection), and thrombocytopenia (hemolytic uremic syndrome [HUS]) are all present on a complete blood count (CBC).

Basic metabolic panel (BMP) results include nonanion gap metabolic acidosis, serum electrolytes, BUN, and creatinine (which may rise with volume depletion).
Occult blood in stool (IBD, intestinal ischemia, and some bacterial infections)
Fecal leukocytes can help distinguish between inflammatory and noninflammatory diarrhea, but they should not be used to identify the infectious etiology of diarrhea. Stool ova and parasites can also help.
- Multiplex stool testing (PCR testing for parasite, viral, and bacterial causes of diarrhea) - Stool culture
- C. difficile toxin (particularly if you have IBD, were recently hospitalized, or recently used antibiotics) 
Giardia ELISA > 90% sensitive in at-risk group; abdominal radiographs (flat plate and upright) if significant abdominal discomfort or worry for blockage; abdominal CT scan preferable to assess intraabdominal illness.


Other/Diagnostic Procedures

When standard blood and stool tests reveal an unclear diagnosis in patients with recurrent diarrhea, or if empiric or supportive medication is inadequate, consider sigmoidoscopy or colonoscopy.

In order to check for CMV colitis in immunocompromised people, consider colonoscopy.

Management The key to a successful course of treatment is oral rehydration and electrolyte control.
Oral ingestion, if tolerated—"if the gut works, use it"
Rehydration with balanced electrolyte solutions is advised for older patients with watery, severe diarrhea
IV fluids if the patient is very dehydrated or is unable to tolerate oral rehydration

First Line of Medicine

Consider prescribing empiric antibiotics (fluoroquinolones or macrolides) to patients who exhibit symptoms of severe illness, systemic infection, or TD.
- Fecal leukocytes, bloody diarrhea, and fever
- Immunodeficient host
- Indicators of a serious volume decrease
Adapt antibiotics based on the results of stool cultures.
E. histolytica: metronidazole 500 to 750 mg PO TID for 7 to 10 days, tinidazole 2 g PO daily for 3 to 5 days. Giardia: metronidazole 250 mg PO TID for 5 to 7 days, tinidazole 2 g PO once.
- For Shigella, use ceftriaxone 1 to 2 g IM/IV daily for 5 days, or ciprofloxacin 500 mg PO BID for 3 to 5 days.
Azithromycin 500 mg PO daily for 3 to 5 days or erythromycin 500 mg PO QID for 5 days are recommended for campylobacter.
The Infectious Disease Society of America currently suggests fidaxomicin 200 mg PO BID for 10 days as the initial course of treatment for C. difficile. As an alternative, vancomycin 125–500 mg PO QID for 10–14 days might be utilized; fecal microbiota transplant should be taken into consideration in cases of recurring mild to moderate C. difficile infections.
- TD: Ciprofloxacin 500 mg PO BID for 1 to 3 days, azithromycin 500 mg PO daily or 1 g PO daily for 1 to 3 days, and rifaximin 200 mg PO TID for 3 days. These medications can be combined with loperamide; in situations of moderate TD, loperamide or BSS may be administered alone.

General considerations: Unless the illness is caused by Salmonella typhosa, the patient is feverish, or their immune system is impaired, antibiotics are not advised for Salmonella infections.
– Due to the danger of HUS, people with E. coli 0157:H7 shouldn't use antibiotics.
- Foodborne toxigenic diarrhea is not suggested for the use of antibiotics.
- When treating patients with febrile or bloody diarrhea or colitis brought on by antibiotics, avoid using antimotility medications (such as loperamide).
– When used with antibiotics, antimotility medicines may hasten TD recovery.
- The treatment of mild TD does not involve the use of antibiotics.

Additional Therapies 
Bismuth subsalicylate could aid in reducing the frequency of diarrheal stools.
Probiotics are advised for the treatment of acute infectious diarrhea in the presence of symptomatic IBS, the prevention of antibiotic-associated diarrhea and the recurrence of C. difficile infection.

Use of probiotics >1010/g may be beneficial for people with diarrhea brought on by antibiotics.

Probiotics should not be taken by immunocompromised patients.

Admission
Except for patients who are gravely unwell and exhibit signs of volume depletion, outpatient management.

Diet 
It is advised to refeed orally right away. 
Regular diets work just as well as restrictive ones.
Coffee, alcohol, dairy products, fruits, vegetables, red meats, and highly spiced foods may aggravate symptoms during periods of active diarrhea. The traditional bananas, rice, applesauce, and toast (BRAT) diet has little evidence-based support (despite widespread clinical use) and may lead to inadequate nutrition.


Prognosis If proper hydration is kept up, acute diarrhea is rarely fatal.
Volume depletion, shock, and sepsis are among the complications. HUS caused by E. coli 0157:H7, Guillain-Barré syndrome brought on by C. jejuni, reactive arthritis brought on by Salmonella, Shigella, and Yersinia, and functional bowel problems (such postinfectious irritable bowel syndrome [PI-IBS]) are also common.